Prof Joe
I looked up this web site after reading, an article in the Sydney Morning Herald with the Bi line “Residents fall victim to preventable deaths”, a story which was then bastardised by Karl Steffenovic on the Today Show , with comments such as “there is a crisis in aged care” and ” are there cover ups”. Sensationalism at is best.
The article sites a stat that preventable deaths have increased from 1.2 per 1000 admissions to 5.3 per 1000 over the 13 years of your study, but naturally the reporter fails to explain the methodology of your research. the effect of the numerous variables or any conclusions to be drawn, or the reliability of the data. As you would understand, with the massive increase in the provision of Home Care and Low Care Facilities, admissions to Nursing Homes are now far more frail and then they were even 5 years ago let alone 13 years ago. ( I will try to access your actual study)
Comments attributable to yourself about Risk seem at odds with the thrust of this web site. RESIDENTS ARE ABLE TO TAKE RISKS is part of the determination of compliance under standard 3.9 -Choice and decision making – in the accreditation standards.
The SMH article included a case where a woman sustained a fall in a nursing home and passed away 6 weeks later, however the cause of death is not mentioned but a vague reference from a GP that …. think the fall hastener her death. would you count the case as a preventable death even if the cause was heart attack or stroke or respiratory failure?
Falls are part of aged care life, and indeed aged life in general. It is balance between freedom of choice and life style and risk assessment. Falls can be prevented with physical and/or chemical restraint but that is the option of last resort. If a resident does not want bed rails but is at risk of attempting to self mobilise. You can lower the bed and then they try to walk around at night and fall – You can’t watch every resident every minute of every day.
Duty of care is a great legal term. Foreseeable Risk is another great legal term of used in negligence cases. Falls data indicates that about 10% of residents sustain 90% of unwitnessed falls – and that 10% you watch very closely but they still have falls because its in their nature and they will almost deliberately try to mobilise ” when no-one is watching..”

So inspiring to listen to. Messages like this often miss those who could benefit the most from hearing them. ie. people who malignantly position people with dementia, focus on ‘disabilities’ rather than supporting and maintaining abilities, preserving personhood. etc

I have come home after spending six weeks in a Aged Care Rehab. facility. I am 75 y/o with thankfully most of my mental capacity. It was a profound experience and I came away almost traumatised. I have spoken to as many people who would listen to me about my experience and the mentally sterile existence for the elderly . They are not being stimulated and after a month they seem to becoming institutionalised.
Silent meals three times a day were intolerable. There was a cooking morning for an hour a week also regular Rehab. and Doctor’s rounds. I am not being critical of the care.
The unhappy experience of people wandering around with very few activities to keep them sane. Yes, they should be able to take more control of their lives. I do not know professor Ibrahim what I am saying but I would love to help and have a talk with you. Raise an army of volunteer helpers with special skills they can share. I was a florist and the thought crossed my mind that I could teach them flower arrangement. Planting seedlings. book tapes , a friendly animal , art or music. I was drawing every day when I was there and it was remarkable how many people asked me if I could help them draw. .
As if you did not know these things professor but for me I wanted to make a change when I left the facility.

I am writing to you after reading the article on the abc site over the weekend, which I enjoyed immensely and agree wholeheartedly with.

I thought you might be interested to know what Outdoors Victoria is doing in this realm.

Outdoors Victoria is a non-profit Organisation that represents the outdoor community across Victoria. We have been working on a project to get seniors active in the outdoors in conjunction with Vic Health, Seniors Online and the Australian Camps Association.

This is our active seniors landing page and our introductory page to nature-based activities in Vic The latter page is not only for Seniors but has a seniors emphasis and each individual page has seniors card links for activities.

We are also about to launch an age-friendly resource kit for rec. clubs.

My mother is 84 and very active (within the constraints of polymyalgia and a range of age-related challenges, including keeping a watchful eye on my father whose memory is proving to be creative). For years she competed in Carriage Driving, with a range of horses – Australian Champion on a number of occasions, even competing in the U.K. in the mid 1980’s. She finally retired from the sport but continued into her 70’s as an instructor and assessor for ‘Driving for the Disabled’, establishing the group that still operates at Mornington Racecourse, Victoria twice a week. Her horse, Bub, went off to have foals. However, 3 years ago she retrieved the horse (not having any more foals) and every 10 days or so I meet mum (where Bub is agisted as Mum can’t manage a horse on her property any more) and we harness Bub and Mum and I go for a drive of 6-8 kms. I need to help with the heavier bits and pieces of harnessing up – but the reins are all mum’s. Getting into the ginker is assisted by modified steps and a solid upturned bucket. I am wing-man in case extra power is needed for mum to climb into the ginker. But – when we are out with the mare and mum starts to sing to the horse as it’s trotting or even cantering along the road – I know it is so absolutely vital to her life to continue this. There are risks – which we are well aware of, having competed for years – but an ‘adventure for living’ lasts forever…and I believe (as does mum) that it must be allowed to happen. (I’d include a recent photo here, if you’d like one let me know… Mum and her mare of a week or so ago.) I think the work you are doing is wonderful and long, long overdue. Sincerely, Katrina

This sounds rather like regulatory over-reach to me. I get that aged care facilities/institutions have to be accountable for the things they do and are responsible for . . . but taking responsibility for a resident’s decision to go out and take a risk with a particular activity . . . surely that’s just taking things too far.

It would be a very different issue if the staff are ‘pushing’ someone into doing something that they might think is in their best interests, but to facilitate the resident’s own wishes, that seems perfectly OK to me. But I’m only in my 60s, so what would I know?!

You have neatly captured one of the key factors. While I agree it sounds like regulatory over-reach, the question is why does our society want or accept a situation that promotes safety only? Why do we want to be so protective? What are we scared of happening? Most of the regulators and policy makers I speak to are strong advocates of choice and living life with risk, as are older individuals—what is puzzling is that if most people agree with the concepts—why does it not happen as a routine?

My mother had advanced parkinsons and the nursing home rules was that it was too dangerous for her to eat proper food. She lived on disgusting liquid food for two years. A nurse herself she was well aware of the risk. The argument was that if she choked it would be distressing for staff and other residents. I would take her out and let her eat what she wanted both if us knowing the risk she never choked and had to refuse food altogether and starve to death. A very brave act.

A really important topic that should get more attention. I’ve just finished a post-grad program in the Psychology of Risk run by Dr Robert Long who is the author of four books, the first if aptly titled Risk Makes Sense (see http://www.humandymensions.com). Rob argues there is no learning, and no real living without risk. I’d be happy to more of my learning and other references (books, research etc…) with anyone who is interested. You can drop me a line at robertsams12@gmail.com. Cheers, Rob

Thank for your support. The topic is incredibly important and complex. There are a large number of courses, textbooks and academic research about the topic of risk. It is very kind of you to offer to share resources.
A colleague, Rhonda Nay says there is no life without risk.

I am in my early 60’s and no one is ever putting me in a residential facility. It’s bad enough out here. As a Carer of a like minded person; being invited to bingo, singalongs, bus trips to shopping malls and bloody knitting groups. A new age of relevant “activities”, approaches is upon us. All hail the Boomers who will not tolerate such rubbish. I worked for decades, gained quals and raised a family. I will not be treated like an imbecile and neither is or will my 92, still at home Mother.

Your passion and determination certainly comes through. Our aged care services in Australia are amongst the best in the world. The general views about life in a nursing home tend to be negative, with most young and able-bodied people unable to comprehend that life is worth living and there is still joy in life. While I am also not a fan of bingo there are many people who love it. My partner is a passionate knitter and I have seen some amazing craft work completed by young and old alike.
I tend to argue “horses for course” as long as people do things they enjoy. It is a bit like peoples choice in music, recall the battle between punk and disco in the 1970s and if you want to go back further the emergence of rock and roll.
My question to you is, if baby boomers will not tolerate a lack of choice, why is it OK now?

Thank heavens someone is raising these issues!
I am a GP and I have often witnessed what I would consider to be inappropriate restriction of personal freedom in aged care homes as a result of an overriding concern to minimise risk.
This is in no way the fault of the aged care sector: as well as adverse consequences for an institution, there are possible personal professional consequences for staff members, should any resident suffer accidental harm. The medico legal climate needs to change to recognise that just because a person lives in residential care, it doesn’t mean that all decision making capacity around risk must be borne by the institution.
Currently residents are often unable even to self medicate with paracetamol : this has to be prescribed on a drug chart and dished out by a nurse.
Residents deemed at risk of choking are not permitted to have a cup of tea without thickening agents.
Surely some assessment of mental capacity must be made , and if a person towards the end of their life chooses to risk an earlier demise by enjoying normal everyday activities, then in my opinion it is wrong to restrict them.

Thanks for your support and for being one of the few doctors involved in aged care. You highlight a large number of issues. A key one you raise is the perception of staff about the personal and professional consequences when an older person taking a risk comes to harm. We need everyone involved to be aware that activities have positive and negative consequences and that when a negative consequence occurs we do not rush to blame. It is too easy to be judgmental when we look back at actions and decisions.
The test of our maturity as a society is how we approach situations where significant harm has occurred. That we are able to reflect if a decision to take a risk was explained and understood; that staff took the precautions to manage the risk. The danger is that we approach risk as an “all or none” issue. The example of food causing choking is a classic example. A person should be able to enjoy a cup of tea if they wish, our responsibility as health professionals is to ensure the environment and care provided minimizes the risk of choking. For example, being by the person’s side, having them sit up and supporting them during the activity. What is not alright and what I fear, is that people will say “if you choke that’s your own fault and nothing to do with me”.

Like Sally, I am a GP and totally agree with her comments. I have just stumbled across your website, Professor, and really appreciate the thoughtfulness with which you have raised this issue, as well as the others such as the issue of resuscitation. It has always stunned me that I, as a middle aged adult, can make a decision to bungee jump, parachute and rock climb provided I accept the associated risks, whereas older people who are not cognitively impaired are infantilised; not allowed to walk without assistance because of the risk of falls, and served thickened fluids even after making it clear they have accepted the risk of aspiration because of the desire to enjoy a normal cup of tea. Atual Gawande summed it up in his comment that we want autonomy for ourselves and safety for those we love. Thanks again for publicising the topic.

I always say to the young doctors and nurses “never argue with anyone in their 90s as they are almost always right”. Managed risk is the exact approach we want to see happening more often. The trouble at the moment is the perception that managed risk is NO risk. What are you planning for your 90th birthday?

If the activities ( risky or not ) stimulate the aged to partake in activities, it’s a good thing. The excitement associated because of an increased level of risk might stimulate people to join in and improve their quality of life.

Hi Eric,
As you note, the whole point of life is to live it! Joining in with others is now referred to as improving or enhancing “social inclusion” for individuals—I am amazed how each generation tends to complicate the simple idea of visiting friends and family. Being involved in the world around us certainly does improve quality of life.

at 67 i still take risks i.e. 3am fishing trips.by myself. long clifftop walks keeping a eye out for snakes,bushwalking in very dense bush only just started to carry a phone and a bandage for snake bite, get a bit tired after 8-9km but enjoy the bush

Dear Vic,
I admire your passion for fishing. The only time I would get up at 3am is when I am on-call. I am not much of a morning person. You may be interested to know that medically, we do not consider people to be old until they get to 75 years old! Enjoy the bush, we are very lucky in Australia to have some of the world’s best walks. Remember to take extra precautions in the summer months with the hot weather and may be convince someone to join you when you walk. What’s the most interesting thing to happen when you have been out fishing at 3am?

Doesn’t it depend on the activity in question? It might be totally off the charts for anyone to consider a frail, unwell Mr Jones hiking up Mt Everest for instance -or even walking the Kokoda Trail. But there are other ways a similar experience could be designed, depending on what it is Mr Jones wants from that experience.
– if he wants to revisit Kokoda to remember his War buddies, a Veterans group accompanies frailer people making sure they’re OK and arranging extra medical care if required
-if he wants the exhilaration of being up high, a day trip to a nearby mountain resort with some trail walking might be nice
– if he wants to drive fast, some race tracks arrange accompanied circuits where you’re the passenger in a racing car…

If Mr Jones can express his needs and wants, shouldn’t he be allowed as much scope as anyone else? If he lives ‘in care’, then others have a duty of care to see there’s no undue risk. But the key word is “undue”.

The ideas you present are certainly what we are arguing should happen more often. As you state the key word is “undue” which people interpret in very differently. As a society we think of residential aged care services or nursing homes as being “in care” and when someone is “in care” there is a general expectation a person is kept safe, out of harms way. We need to challenge this idea more. The examples you give demonstrate how a balance can be achieved. Our challenge is to convince family, friends, staff, doctors and lawyers this is reasonable. Thanks for your thoughtful contribution.